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Mark W. Saunders v. Commissioner of Social Security

September 26, 2011


The opinion of the court was delivered by: Wilkerson, Magistrate Judge:


Mark W. Saunders ("Claimant") applied for disability insurance benefits and supplemental security income on December 20, 2005 (Tr. 45-51). Claimant alleged he became disabled on December 9, 2003, due to neck pain, shoulder pain, and anxiety attacks (Tr. 45; 54; 69). The Commissioner denied the claims initially on July 7, 2006 (Tr. 25), and upon reconsideration on October 11, 2005 (Tr. 33; 36). Claimant requested a hearing before an Administrative Law Judge ("ALJ") on December 4, 2006 (Tr. 41). At the hearing held on November 24, 2008, the Claimant amended his onset of disability date to November 1, 2004 (Tr. 8). In a decision dated March, 12, 2009, the ALJ found Claimant not disabled under the Social Security Act (Tr. 8-16). The Appeals Council denied Claimant's request for review on October 22, 2009 (Tr. 1). Thus, the decision of the ALJ became the final decision of the Commissioner. 20 C.F.R. § 416.1481. Skarbek v. Barnhart, 390 F.3d 500, 503 (7th Cir. 2004). Claimant now seeks judicial review of the Agency's final decision pursuant to 42 U.S.C. § 405(g). As set forth below, the decision of the Commissioner is REVERSED and the case REMANDED to the Commissioner for further evaluation of the Claimant's application for disability insurance benefits and supplemental security income in accordance with this opinion. Application for Benefits

Claimant was born on May 6, 1966 (Tr. 63). He was thirty-eight years old on November 1, 2004, the date of his alleged onset of disability. Claimant alleged that he was unable to work due to neck and shoulder pain and anxiety attacks (Tr. 69). Since 1992, Claimant worked as a cashier, construction laborer, general laborer, and driver (Tr. 70-85). He was laid off from his most recent job because he was no longer able to lift or perform the physical requirements of the job (Tr. 69).

Medical Records*fn1

An August 14, 1997, x-ray of the Claimant's lumbosacral spine showed "slight hypertrophic osteoarthritic spurring." There was no evidence of significant vertebral compression and the transverse processes and sacroiliac joints were normal (Tr. 166). The impression was osteoarthritis (Tr. 166). Claimant received a diagnosis of lumbar sprain (Tr. 167).

An August 29, 1997, MRI of Claimant's lumbar spine showed disk herniation at L4-5, moderate narrowing of neural foramina at L5-S1 without disk herniation, and scattered discovertebral degenerative changes (Tr. 200-201). Claimant had surgery on his lumbar spine in December 1997 (Tr. 159).

Claimant was involved in an automobile accident in April 1999. A May 26, 1999, MRI of Claimant's cervical spine revealed a herniated disk at C6-7 with encroachment of the spinal canal, which correlated with left C7 radiculopathy (Tr. 191).

On August 24, 1999, Claimant saw Dr. Robert E. Gardner of Neurological Associates of Cape Girardeau for an evaluation. Dr. Gardner reported that after the April 1999 accident, Claimant had suffered from headaches and neck pain. After a neurological exam, Dr. Gardner determined that the Claimant's symptoms were "of musculoskeletal origin." He noted Claimant's self-report of past MRI with disk herniation and opined that a herniated disk could account for his pain. Dr. Gardner recommended CT, EEG, and EMG testing (Tr. 259-60).

A February 16, 2000, x-ray of the cervical spine showed "marked straightening of the normal cervical lordosis with restriction in range of motion in flexion and extension. The disk spaces were maintained and no fractures were seen. A CT scan of the cervical spine revealed disk herniation at C6-7, extending centrally and to the left, encroaching upon the neural foramina. There was associated bone spurring in the same region (Tr. 277).

A March 7, 2000, MRI of the cervical spine was normal, with normal disk spaces and no indication of disk herniation (Tr. 262).

An April 3, 2000, CT scan showed minimal bulging of the disk annulus at C5-6, eccentric bulging of disk annulus at C6-7 toward the left with early marginal osteophyte formation causing mild narrowing of the left lateral recess, but without evidence of nerve root or cord impingement (Tr. 263). A cervical myelogram performed the same day was normal (Tr. 265). A lumbar myelogram showed degenerative disk narrowing and vacuum disk phenomenon at L5-S1 with unilateral spondylolysis at L5 on the left side with degenerative sclerosis. There was no evidence of impingement on the existing S1 nerve roots. Mild bulging appeared at L4-5, causing minimal narrowing of the lateral recesses but no evidence of nerve root impingement. Early degenerative disk narrowing appeared at L3-4 with anterior marginal osteophyte formation (Tr. 266-67).

A May 1, 2000, MRI of Claimant's left shoulder showed subdeltoid and subacromial bursitis, and tendonitis of the supraspinatus and infraspinatus tendons (Tr. 190).

A September 14, 2001, MRI of Claimant's lumbar spine showed narrowing of the intervertebral disk spaces and desiccated or degenerated disks at L1-2, L3-4, L4-5 and L5-S1, recurrent herniated disk at L4-5, and multilevel discogenic changes and hypertrophic osteoarthritic degenerative changes (Tr. 188).

A September 4, 2002, cervical CT scan revealed no disk herniation or vertebral canal or neural foraminal stenosis, but showed mild degenerative arthritic changes at C5, C6, and C7 (Tr. 276).

On March 26, 2003, claimant saw Dr. Stephen M. Brennan complaining of neck and upper shoulder pain. Dr. Brennan noted tenderness and muscle spasm in right and left trapezius muscles and in the right and left cervical paraspinous muscles. Dr. Brennan performed trigger point injections in those muscles. Dr. Brennan encouraged Claimant to continue with physical therapy and to return as needed (Tr. 237).

An MRI of the cervical spine performed on March 26, 2003, demonstrated disk herniation at C6-7 with possible nerve root impingement (Tr. 239). On December 9, 2003, Dr. Matthew Gornet performed microdiscectomy and anterior cervical fusion at C6-7 (Tr. 353-57).

Between August 2005 and September 2006, Claimant saw Dr. Saeed Khan at the Benton Medical Center twenty three times for chronic neck pain, chronic back pain, and headaches. In February 2006 Claimant also complained of numbness in his left leg (Tr. 324-25). On February 14, 2006, Dr. Khan recommended that Claimant see a neurologist (Tr. 324). During that period, Dr. Khan prescribed muscle relaxants ...

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